REGISTRATION RECORD FOR CHILD RECEIVING CARE AWAY FROM HOME
Child Information
Child Name:
*
Last, First, M.I.
Sex:
Male
Female
Date of Birth:
-
Month
-
Day
Year
Date
Does the child have any known allergies? If yes, please list below.
Desired Start Date
-
Month
-
Day
Year
Date
Child Home Phone:
Please enter a valid phone number.
Child Home Address:
Language Spoken At Home:
Parent 1 Information:
Parent 1 Name:
Last, First, M.I.
Parent 1 Email Address:
example@example.com
Parent 1 Home Address:
Parent 1 Home Phone:
Please enter a valid phone number.
Parent 1 Business Address:
Parent 1 Business Phone:
Please enter a valid phone number.
Parent 2 Information:
Parent 2 Name:
Last, First, M.I.
Parent 2 Email Address:
example@example.com
Parent 2 Home Address:
Parent 2 Home Phone:
Please enter a valid phone number.
Parent 2 Business Address:
Parent 2 Business Phone:
Please enter a valid phone number.
Relative or Guardian:
Relative or Guardian Name:
Last, First, M.I.
Relative/Guardian Home Address:
Relative/Guardian Home Phone:
Please enter a valid phone number.
Relative/Guardian Business Address:
Relative/Guardian Business Phone:
Please enter a valid phone number.
Person to be contacted in case of an emergency (other than parent/guardian):
Emergency Contact Name:
Last, First, M.I.
Relationship to child:
Emergency Contact Address:
Designated individuals authorized to receive child at end of session
Authorized Pickup #1
Last, First, M.I.
Authorized Pickup #1 Relationship to Student
Authorized Pickup #1 Phone Number
Please enter a valid phone number.
Authorized Pickup #2
Last, First, M.I.
Authorized Pickup #2 Relationship to Student
Authorized Pickup #2 Phone Number
Please enter a valid phone number.
Authorized Pickup #3
Last, First, M.I.
Authorized Pickup #3 Relationship to Student
Authorized Pickup #3 Phone Number
Please enter a valid phone number.
Were you referred by a Phase family? If so, who referred you?
th
10
50 1st
Street NE, 6
1839
TTY: 711 • osse.dc.gov
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